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Tomorrow is Thanksgiving, so today I’m with my family, looking at the timeline for tomorrow and discussing when the pies need to go in, who is making the cornbread and calculating how long the turkey needs to cook.

As of today, there will be 12,996 families in the United States who lost a family member to gun violence in 2018…. almost 13,000 Thanksgiving tables with an empty seat from a preventable death – from this year alone.

My second tweet was followed by a long thread of PubMed abstracts with research results showing how we might start decreasing deaths from gun violence. The NRA, interestingly, removed all of those Tweets from their timeline.

#ThisIsOurLane has become a movement. A callous Tweet from the NRA started it, but that’s not what is sustaining it now. As I discussed in this podcast, I think what the NRA did was make physicians realize that this “debate” is not about politics, it’s about lives… human lives… sisters, brothers, mothers, fathers, friends. It’s about our patients and, unfortunately, our colleagues. As a result of what has happened since November 7th, physicians have realized we need two things to move this forward: stories and data. Human beings are not swayed by debates, they are moved by stories. Good decisions can’t be made on emotions alone – we need data and that means research, and funds to do that research.

Commit to questioning what you hear – from both sides. Question whether the fear created by the NRA is to serve another, more political aim… one that you might not completely understand or agree with. Ask questions. Ask for data. Recognize and ignore political rhetoric (from both sides). Keep an open mind.

Support the funding of research into gun violence. Contact your representatives to let them know this a priority for you. This is no different than what we did as a society when we looked at death from car crashes… and developed seat belts, stronger cars frames and air bags. Wouldn’t it be great if we could see the same decrease in gun deaths through research?

If you are in healthcare, tell the stories in a way that respects your patients and their rights… but tell them. If you are on social media, use that platform. Until people realize that these are our siblings, parents, colleagues, and not just statistics, we won’t make progress. We have to move hearts before we can move minds.

I am so thankful for my family, for the opportunity to gather at the Thanksgiving table together, and for the many friends and opportunities that have been given to me. My heart goes out to all families who have lost a loved one to gun violence, including the horrible loss of life by suicide. May you find some small solace in knowing that we are holding you in the light – and that we will continue to work hard to end the tragic epidemic of gun violence in our country.

Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!

The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.

Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.

So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.

Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”

The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?

The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized? (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)

This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.

SURVEY to get the big picture

QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.

During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.

*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)

After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.

Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language. The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts. That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)

Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!

Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later. More is better. Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!

Another thing about our brains and learning. Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.

Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.

People sitting next to you in your study areas are going to look like they have it more together than you do. It might be true… but it probably isn’t. If someone has a study technique that looks like it will work for you, by all means try it! Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,

Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.

Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.

It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.

I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.

Welcome to the best career in the world! We are all happy you are here!

Dr. Marc Rowe is one of the truly great pediatric surgeons of our era. His work in newborn physiology profoundly changed how babies were and are taken care of in intensive care units. His prolific research, along with the many people he trained, has unquestionably affected the lives of hundreds of thousands of newborns. He has taken on creative work as a writer and wood carver in his retirement. Dr. Rowe is one of my personal heroes and, when I read this essay he recently posted, I asked his permission to post it here to be able to share it with you.

I am troubled by what is happening to our Country. Principles and ideals – truth, honor, kindness, diversity compassion and love and protection for the people, the creatures and the environment we share has been replaced by selfishness, prejudice, lies and a willingness to compromise in order to gain material wealth and power. What is particularly frightening is the effect the current leadership may have on our greatest gift, our children- the message sent – that you can be dishonest, unfaithful to your loved ones, lie, be a racist, a bully and a braggart and still become the most powerful person in the world and be supported by many of our religious and political leaders. I am confused – does this mean that these political and religous leaders would choose our current president to be a role model for their children and grandchildren?

As I watched this sad period in the history of our country unfold I was overtaken with a sense of powerlessness. I then remembered two lessons I learned during my career as a pediatric surgeon. The first occurred during my first job as an assistant professor of surgery. I was incensed by an episode of academic politics and was tempted to speak out but realized if I did I would pay a price. I vented my frustration to my wise and famous boss, Dr. Mark Ravitch, a battle scarred warrior of the political and academic world. He said – “before Socrates drank the hemlock he began his defense by saying –never let it be said that I had a podium and failed to speak. – You have a big mouth use it”.

The second lesson came later when I became depressed realizing the huge number of children suffering from potentially correctable diseases and abnormalities and how little one person could do. I then began to think about the ripple effect – the ever-expanding effect that even one person can have by teaching and striving to be a role model. I realized that young people are astute observers and learn not by what their teachers say but by the way they act, how true they are to the principles they teach and most important by not selling out when being principled becomes painful and dangerous. Kids spot phonies a mile away.

Three people I have greatly admired, Mother Teresa, the Dalai Lama and Robert Kennedy all have spoken of the ripple effect. To quote Robert Kennedy who spoke of the ripple effect during the tumultuous civil rights strife – “Each time a man stands up for an ideal, or acts to improve the lot of others, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”

This carving I call the Ripple. The pond and thrower is carved from a branch and cross-section of bass wood, the shoreline is made from Sanibel sand and the stone in the pond is a small piece of river rock.

There is a longstanding superstition in medicine that you never wish someone a quiet call night, sort of the medical equivalent of never wishing an actor a good show. We are trained in science, so all physicians know this is silly…and yet…

I teach embryology to wonderful first year medical, nurse anesthetist and PA students. Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.

As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.

A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.

A young couple comes to their gynecologist for a routine screening ultrasound. Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.

Let’s talk ethics.

We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.

Let’s talk about listening.

When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.

As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient. Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.

Today I have the incredible joy of talking to the medical students on our rotation. No agenda, just a conversation that they requested for some “advice”. They just started their surgery rotation last week and it’s their first rotation. First rotation, beginner’s mind, unbridled enthusiasm… it is so wonderful!. I decided I would come up with what I wish someone had told me at the beginning of my rotations…

This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.

Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat, keep on a piece of paper in your wallet or on your wrist

Learn to keep a “beginner’s mind”. When I was a student on core medicine I had a senior resident that showed me what beginner’s mind looks like. It was 2am and I was tired. We were seeing a gentleman at the VA hospital for his diabetes, hypertension and some electrolyte abnormalities. I presented the patient to the resident and then we went to see him together. He had a rash, which I thought was so insignificant that I didn’t even include it in my presentation. But, instead of scolding me, this resident got excited. Yes, you read that correctly, 2am and excited about a rash – because he didn’t know what it was. (This next part will date me, but it’s a great example to make us grateful for the access we have to information now). He called security and had them open the library. We spent a wonderful hour looking through books – like a treasure hunt when we were little kids – until we found the rash in one of the books. We were laughing, excited and couldn’t wait to get back to start the appropriate therapy.

Understand what you are going to learn (the big picture)

On every rotation, you will be given a list of learning objectives. By all means, know them, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).

You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.

Learning is iterative. You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema. If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.

Pay attention to ergonomics, diet, exercise and sleep. Most importantly, take care of yourself emotionally and spiritually. You can’t learn or serve others if your tank is empty. Come up with what is important for you and make a list. Seriously. Make a list of what you find helps you stay on track and then check it off every day. Look at it before you go to bed. Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.

We have the most amazing job on earth. When the administrative issues or political conflicts get to you (and they will), just remember – you get to take care of another human life with the goal of relieving their suffering. What could be more important than that?

The other day, while I was looking at my Twitter feed, I came across this amazing thread by Dr. Jennifer Cowart. I was so moved by this heartfelt plea to our elected officials that I asked her permission to post it here.

Female doctor with the stethoscope holding heart

I have never seen a patient who did not deserve healthcare.

I have seen people, rich and poor, who do not take care of themselves. Who drink too much, eat bad food, smoke, use drugs, drive recklessly, etc. If you smoke and get lung cancer, or if you didn’t smoke and get lung cancer, you deserve healthcare.

I have seen people, rich and poor, who believed themselves entitled to whatever care they wanted, at whatever cost, whether it was evidence-based or not. It didn’t change the fact that they deserved appropriate healthcare.

In fact, it is interesting that “entitled” is an epithet more often thrown at an “undeserving” poor person than a rich person with the same behavior and attitude.

I treat “good” and “bad” people. People I wouldn’t let in my house. It doesn’t matter. I’ve treated registered sex offenders. I don’t ask what they did. I take care of their pneumonias, their heart failure, their cirrhosis. They deserve healthcare. My care.

I took my (healthy, neurotypical) baby to a specialist the other day. We passed many children with (visible) special needs. A girl with a trach in a push chair. A teenager escorted by her father with CP. Children with various genetic syndromes. They deserve healthcare.

That could have been us. If not for the luck of genetics, my children could be those children. Blessings, but also requiring significant care, time, money, and resources. Those children are worth as much as mine and deserve their healthcare.

To me, the fact that it will cost a lot of money to ensure everyone has healthcare coverage is secondary to the fact that everyone deserves it. If we decide everyone deserves it, we will finance it. Expensive things can be worthwhile. Healthcare is one of those things.

I have seen cancer patients lose their insurance and not know where their care will come from. Chemo regimens interrupted. Radiation not given. “Lost to follow up.” I have been in those rooms, held those hands, wiped those bitter tears.

When you’ve worked your whole life, had private insurance, got cancer before you are old enough for Medicare, get too sick to work, lose job, lose insurance, have to wait for disability/Medicaid to kick in… this is pain like you haven’t seen. Those people deserve healthcare.

I know there’s the flipside. People who never worked. Maybe they really were truly lazy, or maybe they were caretakers and never worked outside the home (doing invisible work). Some of these folks are rich, some poor. I treat them all.

Illness doesn’t respect your work history. “Bad behavior” may increase risk of bad outcomes, but we transplant a lot of livers into cirrhotics who drank. Cancer strikes a lot of folks who never smoked, who got HPV from their spouse, who did nothing “wrong.”

The only category I see that we consistently say as a country who doesn’t “deserve” their care are the poor. Sure, people judge alcoholics or people dependent on opioids, but we haven’t made huge moves to dump all of those folks off their healthcare programs.

Yet Congress tried to cut millions of people out of Medicaid. Give them the “freedom” to “choose” their care—which they can’t afford. They didn’t cut smokers off, or alcoholics, or diabetics who eat sugar, or heroin users. Just poor people, those “undeserving.”

We are still waiting for CHIP to be funded. Guess who’s children are covered under CHIP? Not the kids of smokers. Kids of working people who don’t make much, but earn too much for Medicaid. In other words, people who don’t have enough $ to “deserve.”

I reject the premise that money is what makes you worthy of my time and care. I understand that healthcare must be financed. My time is not free. I am not a volunteer. But if you have pneumonia, my worry is not how will you pay, but how to treat you.

So figure out how to pay for it, because everyone deserves to get treatment for their special needs child, their cancer, their pneumonia. To get that treatment, and not be bankrupted by it. Everyone deserves basic healthcare.

Jennifer B. Cowart, MD works as a hospitalist in Jacksonville, Florida. She is a graduate of the The University of Texas Health Science Center at Houston and trained in Internal Medicine at Baylor College of Medicine followed by a fellowship in Clinical Pharmacology and Hypertension. She then served as the Chief Resident in the Quality and Patient Safety (CRQS) program at the Michael E. Debakey Veterans Affairs Medical Center.

An Instapot. I’ve long been a fan of pressure cookers, but the Instapot takes it to the next level. This is my new favorite kitchen tool and it’s high on my list because it both saves time and increases healthy food consumption!

A subscription to Headspace. This might seem counter-intuitive since it adds a 10 minute task to their day… but there are data (and lots of testimony) that a daily mediation practice “expands time” by decreasing stress.

If they live close enough to walk or bike to school/work, think about something that might help them combine that commute with getting some exercise. How old is their bicycle? How about panniers to store gear on a bike? Would a great backpack help if they are likely to walk? How about a gift certificate to a bicycle shop?

Your time. Can you cook some meals once a month and put them in their freezer?. Do laundry? Bake cookies and mail them? Get their car washed? Make an elaborate certificate with something you could do for them and wrap it as a present.

“Have you ever gotten raspberries home and within a day they are mush with white stuff on them?”

He had my attention.

“The problem is that home chefs don’t keep their refrigerator cold enough. They should be set at 40 degrees.”

Hmmm…

So I’ve been experimenting and … it works! (not that I doubted you, Shawn :-).

Step 1. Decide what you are going to eat for the week.

This planning is essential. It takes me 20-30 (very enjoyable) minutes to find recipes in a magazine (Clean Eating and Cooking Light are my favorites), one of my cookbooks or on line. Here’s what we’re cooking this week:

This is what makes it work in terms of efficiency. For the rest of the week, when you get home, everything will be washed, cut up and ready to throw in the pan. I timed myself and it took 1 hr 22 minutes to turn the pile of veggies you see above into this:

An hour and a half is nothing compared to the time it takes when you get home late and really don’t want to do it. Turn on some music, chop while you are watching some football.. it is a great return on investment to insure you eat well!

Wash the other produce, cut everything up for all the recipes, spin dry them and put them in your 40 degree refrigerator. (If you don’t own one, get a lettuce spinner.)

Wash the fruit and dry it before you put it in the refrigerator.

One other tip…. Make stock! I throw all the vegetable bits (peels, seeds, etc) into a pot with water and make vegetable stock while I’m working. In addition to using this stock for any soup we decide to make, we use it instead of water for rice or pasta to increase the flavor.

For the last few days I’ve been part of the amazing “ride out” crew of doctors, nurses, and support staff covering Texas Children’s Hospital during Hurricane Harvey and the overwhelming aftermath of flooding in Houston. Since I live in Houston, I have been asked by many, in person and on Twitter, what they can do to help.

Please let me know via Twitter (@drmlb) or in the comment section below if you have recommendations to add to the list below.

Texas Diaper Bank . It’s amazing how this is always a big need in crisis situations. This group does a great job keeping baby bottoms covered!

Houston Coalition for the Homeless A group dedicated to caring for the homeless in Houston. Unfortunately, there is little doubt that we will be seeing an increase in homelessness after this disaster, so their work will be even more important.

Hospital chaplaincy programs are always in need of resources and provide important spiritual support during times of crisis. You can donate to spiritual care or other programs for the hospitals in the Texas Medical Center here: